Appendix 20: Vaccine Priority Group Recommendations

Appendix 20: Vaccine Priority Group Recommendations

Vaccine Priority Group Recommendations*

Tier / Sub-Tier / Population / Rationale
1 / A / ·  Vaccine and antiviral manufacturers and others essential to manufacturing and critical support (~40,000)
·  Medical workers and public health workers who are involved in direct patient contact, other support services essential for direct patient care, and vaccinators (8-9 million) / ·  Need to assure maximum production of vaccine and antiviral drugs
·  Healthcare workers are required for quality medical care (studies show outcome is associated with staff-to-patient ratios). There is little surge capacity among healthcare sector personnel to meet increased demand
B / ·  Persons > 65 years with 1 or more influenza high-risk conditions, not including essential hypertension (approximately 18.2 million)
·  Persons 6 months to 64 years with 2 or more influenza high-risk conditions, not including essential hypertension (approximately 6.9 million)
·  Persons 6 months or older with history of hospitalization for pneumonia or influenza or other influenza high-risk condition in the past year (740,000) / ·  These groups are at high risk of hospitalization and death. Excludes elderly in nursing homes and those who are immunocompromised and would not likely be protected by vaccination
C / ·  Pregnant women (approximately 3.0 million)
·  Household contacts of severely immunocompromised persons who would not be vaccinated due to likely poor response to vaccine (1.95 million with transplants, AIDS, and incident cancer x 1.4 household contacts per person = 2.7 million persons)
·  Household contacts of children <6 month olds (5.0 million) / ·  In past pandemics and for annual influenza, pregnant women have been at high risk; vaccination will also protect the infant who cannot receive vaccine.
·  Vaccination of household contacts of immunocompromised and young infants will decrease risk of exposure and infection among those who cannot be directly protected by vaccination
D / ·  Public health emergency response workers critical to pandemic response (assumed one-third of estimated public health workforce=150,000)
·  Key government leaders / ·  Critical to implement pandemic response such as providing vaccinations and managing/monitoring response activities
·  Preserving decision-making capacity also critical for managing and implementing a response
Tier / Sub-Tier / Population / Rationale
2 / A / ·  Healthy 65 years and older (17.7 million)
·  6 months to 64 years with 1 high-risk condition (35.8 million)
·  6-23 months old, healthy (5.6 million) / ·  Groups that are also at increased risk but not as high risk as population in Tier 1B
B / ·  Other public health emergency responders (300,000 = remaining two-thirds of public health work force)
·  Public safety workers including police, fire, 911 dispatchers, and correctional facility staff (2.99 million)
·  Utility workers essential for maintenance of power, water, and sewage system functioning (364,000)
·  Transportation workers transporting fuel, water, food, and medical supplies as well as public ground public transportation (3.8 million)
·  Telecommunications/IT for essential network operations and maintenance (1.08 million) / ·  Includes critical infrastructure groups that have impact on maintaining health (e.g., public safety or transportation of medical supplies and food); implementing a pandemic response; and on maintaining societal functions
3 / ·  Other key government health decision-makers (estimated number not yet determined)
·  Funeral directors/embalmers (62,000) / ·  Other important societal groups for a pandemic response but of lower priority
4 / ·  Healthy persons 2-64 years not included in above categories (179.3 million) / ·  All persons not included in other groups based on objective to vaccinate all those who want protection

*** http://www.hhs.gov/pandemicflu/plan/appendixd.html

Appendix 21: Antiviral Drug Priority Group Recommendations

Group
Rationale
1 / Patients admitted to hospital*** / Consistent with medical practice and ethics to treat those with serious illness and who are most likely to die.
2 / Health care workers (HCW) with direct patient contact and emergency medical service (EMS) providers / Healthcare workers are required for quality medical care. There is little surge capacity among healthcare sector personnel to meet increased demand.
3 / Highest risk outpatients—immunocompromised persons and pregnant women / Groups at greatest risk of hospitalization and death; immunocompromised cannot be protected by vaccination.
4 / Pandemic health responders (public health, vaccinators, vaccine and antiviral manufacturers), public safety (police, fire, corrections), and government decision-makers / Groups are critical for an effective public health response to a pandemic.
5 / Increased risk outpatients—young children 12-23 months old, persons >65 yrs old, and persons with underlying medical conditions / Groups are at high risk for hospitalization and death.
6 / Outbreak response in nursing homes and other residential settings / Treatment of patients and prophylaxis of contacts is effective in stopping outbreaks; vaccination priorities do not include nursing home residents.
7 / HCWs in emergency departments, intensive care units, dialysis centers, and EMS providers / These groups are most critical to an effective healthcare response and have limited surge capacity. Prophylaxis will best prevent absenteeism.
8 / Pandemic societal responders (e.g., critical infrastructure groups as defined in the vaccine priorities) and HCW without direct patient contact / Infrastructure groups that have impact on maintaining health, implementing a pandemic response, and maintaining societal functions.
9 / Other outpatients / Includes others who develop influenza and do not fall within the above groups.
10 / Highest risk outpatients / Prevents illness in the highest risk groups for hospitalization and death.
11 / Other HCWs with direct patient contact / Prevention would best reduce absenteeism and preserve optimal function.

*The committee focused its deliberations on the domestic U.S. civilian population. NVAC recognizes that Department of Defense (DoD) needs should be highly prioritized. A separate DoD antiviral stockpile has been established to meet those needs. Other groups also were not explicitly considered in deliberations on prioritization. These include American citizens living overseas, non-citizens in the U.S., and other groups providing national security services such as the border patrol and customs service.

**Strategy: Treatment (T) requires a total of 10 capsules and is defined as 1 course. Post-exposure prophylaxis (PEP) also requires a single course. Prophylaxis (P) is assumed to require 40 capsules (4 courses) though more may be needed if community outbreaks last for a longer period.

***There are no data on the effectiveness of treatment at hospitalization. If stockpiled antiviral drug supplies are very limited, the priority of this group could be reconsidered based on the epidemiology of the pandemic and any additional data on effectiveness in this population.

*** http://www.hhs.gov/pandemicflu/plan/appendixd.html

Appendix 22: Mass Clinic Management

A pre-established off-site occupational health clinic(s) location is important in managing HCW health issues. This pre-planning is especially important when the in-hospital OH clinic becomes overwhelmed or when the hospital is quarantined.

When determining a location, consider:

§  ample parking

§  location(s) close to majority of HCW’s home address

§  ability to secure the building; identify who will do this

§  availability of restrooms

§  availability of space for staff’s rest breaks and meals

§  hours of operation

§  staffing of clinic, including clerical

§  available equipment in building

§  additional supplies needed: clerical and clinical (where to obtain items; who will deliver them; who will do set up)

§  drawn floor plan to include flow of HCW/work processes (e.g. registration, vital signs (if needed), education center, consent signing, treatment/vaccination, holding area (rule out reactions with vaccinations)

§  directional signs

§  meals for clinic workers (who will provide food; who will deliver; storage of food, clean-up)

§  routine cleaning/maintenance of environment: who and how often

Appendix 23: Strategies for the Use of Anti-Viral Medications

Inter-Pandemic and Pandemic Alert Periods

§  Continue the administration of seasonal influenza and pneumococcal vaccine to reduce the possibility of co-infection and to maintain and develop influenza vaccination infrastructure.

§  Continue the use of antivirals to control healthcare associated outbreaks.

§  Continue to treat all patients admitted to the hospital with influenza within 48 hours.

§  Use antivirals in the medical management of novel cases of influenza as outlined in clinical protocols.

§  Plan for the implementation of treatment, prophylaxis, and PEP protocols.

§  Develop plans to implement distribution of antivirals to priority groups.

Pandemic Period - No Pandemic Influenza Detected in the United States or only Sporadic Cases Reported in the United States

§  Continue the administration of seasonal influenza and pneumococcal vaccine to reduce the possibility of co-infection, and to maintain and develop influenza vaccination infrastructure.

§  Continue the use of antivirals to control nosocomial outbreaks.

§  Plan for the use of antiviral drugs in the management of persons infected with novel strains of influenza and their contacts.

§  Target treatment to influenza patients admitted to a hospital that present within 48 hours of symptom onset.

§  Administer antivirals to all persons sick with influenza that enter the hospital based on clinical algorithms. Do we have these?

§  Begin treatment of patients with influenza-like illness and a positive rapid antigen test for influenza A.

§  Base the continuation of treatment decisions on laboratory confirmed subtype identification of the pandemic strain by viral isolations, RT-PCR, or other means recommended by CDC or the severity of disease and susceptibility of the infective strain in illness caused by other influenza subtypes.

§  Help to develop and implement health guidance that encourages drug-use practices that minimize the development of drug resistance.

Pandemic Period - When Pandemic Influenza is Detected in the United States

With increasing disease activity base treatment decisions on:

§  Laboratory confirmation of infection with a pandemic subtype,

§  Detection of influenza A by rapid antigen test, or

§  Epidemiologic and clinical characteristics.

§  Initiate treatment before laboratory confirmation is obtained.

§  Continue treatment awaiting confirmatory tests.

§  Target prophylaxis to priority groups.

§  Use PEP to control small well-defined disease clusters and to protect individuals with a known exposure to a pandemic virus, such as household contacts.

§  PEP may be used to protect those prioritized during the period between vaccination and the development of immunity.

§  If possible reserve the use of antivirals for prophylaxis only during period of peak viral circulation if that information is available.

Appendix 23: Strategies for the Use of Anti-Viral Medications (Con’t.)

Pandemic Period – When There is Widespread Transmission of Pandemic Influenza in the United States

As the pandemic becomes more widespread treatment decisions are made more on clinical characteristics and epidemiologic features. Laboratory confirmation will no longer be necessary.

§  Treat those at highest risk of severe illness and death if antiviral supplies are limited.

§  Decrease use of prophylactic antivirals as needed once a vaccine is available.

§  Continue to administer antiviral prophylaxis between the first and second dose, or until immunity develops if recommended.

§  Continue to administer antiviral prophylaxis to those for whom the vaccine is contraindicated or whose response to the vaccine is likely to be inadequate.